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364 Challenging Concepts in Urological Surgery
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Traumatic events
Between 4% and 8% of males can present with TT and acute scrotum secondary to trauma. However,
it is often difficult to differentiate this from a scrotal haematoma.
6
Genetic factors
The role of genetic factors as a cause of TT are unclear as some animal models have not translated to human
studies. However, more recently INSL3 and its receptor RXLF2 have been shown to be associated with TT.
7,8
Learning point Pathophysiology
The twisting of the spermatic cord as the testis torts results in ischaemia secondary to reduced blood
flow. This initiates a cascade of biochemical and cellular pathways resulting in tissue necrosis. There is
no predisposition to laterality. A small study reported that TT was right sided in 48% compared to 52%
on the left.9 The reported range of the degree of torsion are 180° to 1080°, with a median of 360° in
the salvage group compared to 540° in the orchidectomy group.
9,10
On examination, the patient looked well with stable vital signs. On focused clinical
examination, the right hemi- scrotum looked swollen in comparison to the left side,
with associated erythema of the right hemi- scrotal skin. The right testis was also tender
to touch. The right testis was higher than the left in position, with absence of the
cremasteric reflex. Urine dipstick test came back as negative.
Clinical tip Diagnosis
The time to diagnosis is critical in TT. The three main phases can be categorized as acute (within 24
hours), subacute (1– 10 days), and the chronic phase (>10 days). Ideally, a diagnosis should be made
within 4 hours; however, delayed presentation may delay surgical intervention.
The diagnosis of torsion is based on history, symptoms, and physical signs.
Adolescents with TT can present with sudden onset of unilateral scrotal symptoms including pain,
swelling, erythema, as well as signs of nausea, vomiting, and occasionally fever. Other non- specific
symptoms include abdominal pain and urinary dysfunction.
Classic findings on clinical examination can include:
● Positive Prehn’s sign (elevation of the scrotum does not improve pain symptoms)
● Brunzel’s sign (high- riding testis with horizontal lie)
● Ger’s sign (retraction of scrotal skin associated with BCD)
● Absence of the cremasteric reflex.
11– 14
14
15
16
Expert comment Diagnosis and predictive models
The diagnosis of TT using clinical examination alone can be challenging. Predictive models have been
described to assist the clinician in diagnosis. These have included scoring systems17 or specific factors
including absence of ipsilateral cremasteric reflex, nausea and vomiting, and scrotal skin changes
which have been described as predictive factors. Other factors include time to presentation,
18,19
heterogeneity on ultrasound images, and high position of the testis.
Studies have reported a ‘high lie’ in only 33– 55% of cases.20 The absence of the cremasteric reflex can
be associated with other conditions and has a specificity of only 66%.
21,22
The diagnosis of torsion can
be misleading and includes several other differential diagnoses (Table 37.1).
Urine analysis
Diagnostic yield is often improved with the use of dipstick urine analysis to eliminate infective
23
causes.
Table 37.1 Suggestive sign for common differentials of testicular torsion
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Testicular torsion Torsion of appendix Epididymo- orchitis
Nausea
Severe pain
No history of trauma
Lower abdominal pain
Blue dot associated with
necrosis of the appendix
Isolated tenderness of upper
pole of testis
Earlier age
History of trauma
Fever
Tenderness secondary to
inflammation
Often sexually active
Puberty and older males
Epididymal tenderness
The radiographer performed an urgent scrotal ultrasound, which revealed enlargement of the right testis, a small hydrocele, and a marked reduction in vascularity of the
right testis in comparison to the left.
Learning point Imaging
Unilateral testicular pain, swelling, and high lie are non- specific, and therefore make a clinical
diagnosis difficult. Imaging techniques can be used as an adjunct to assist in the diagnosis, particularly
in cases of delayed torsion (>24 hours).
Colour Doppler ultrasound is the most utilized imaging modality with a specificity of 97– 100% and
sensitivity of 63– 99%.
associated with the twisted spermatic cord.
A novel method of ultrasound scanning is contrast enhanced ultrasonography which has been
reported to improve visualization of the vasculature compared to standard colour Doppler for
smaller testes such as neonates and early TT. This has a sensitivity of 96% and specificity of 100%.
Interestingly, SonoVue®, the agent used for contrast ultrasound, is not licensed for use in children in
Europe. It is used in a few centres in the UK.
Both scintigraphy and dynamic contrast- enhanced subtraction magnetic resonance imaging have
comparable sensitivity and specificity to ultrasonography.
sensitivity and ability to differentiate between TT and other acute scrotal pathology. However, it is
expensive, not widely available, with little expertise, and is dye dependent. It also would lead to a
delay in diagnosis and therefore has an academic use rather than utility in routine clinical practice.
Scrotal scintigraphy requires the use of intravenous 99mTc- pertechnetate radionuclide dye to
identify cold spots which highlight absence of the microcirculation. Late hyperperfusion in delayed
presentation of TT can give a false- positive signal and therefore this test is more sensitive in the
early stages of torsion. However, again delayed diagnosis, cost, and radiation exposure reduce the
availability of this modality.
However, ultrasonography does not accurately recognize the early phase of torsion.34 Associated signs
are scrotal wall swelling, abnormal positioning of the testis or epididymis, enlargement of the testis, as
well as the presence of a reactive hydrocele.
Evidence base Guidelines on imaging
The National Institute for Health and Care Excellence guidelines in the UK do not recommend the
use of any imaging studies in managing of the acute scrotum if torsion is clinically suspected as this
may delay management and increase the risk of testicular infarction and orchidectomy.36 However,
the European Association of Urology guidelines (paediatric), recommend Doppler ultrasonography
due to its high sensitivity ranging from 63% to 100% with the aim to minimize the number of
cases requiring surgical exploration. It is stated clearly that this should not delay the surgical
management37 (Table 37.2).
14,23– 25
Other useful signs are the identification of the whirlpool sign which is
5,33
38
26
15,35
28– 31
The advantages include a higher
25,27
32
365Case 37 Testicular torsion controversies
Evidence base Colour
Doppler versus high- resolution
ultrasonography
In a multicentre study in 2007,
colour Doppler was compared to
high- resolution ultrasonography in
surgically verified cases of torsion.
The colour Doppler was inferior
at identifying reduced flow; 76%
compared to 96% of cases of
twisted spermatic cords on highresolution ultrasound scanning.
366 Challenging Concepts in Urological Surgery
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Table 37.2 Summary of different guidelines
Clinical tip Management
Testicular torsion is a surgical
emergency that requires prompt
surgical exploration and detorsion.
The testis may be excised if
unsalvageable or fixed if viable.
European Association
of Urology
37
Doppler ultrasound is an effective imaging tool to evaluate the acute
scrotum and comparable to scintigraphy and dynamic contrastenhanced subtraction magnetic resonance imaging. This should
not delay the intervention
National Institute for
Health and Care
Excellence
36
In patients with a history and physical examination suggestive
of torsion, imaging studies should not be performed as they
may delay treatment, therefore prolonging the ischaemic time.
Negative surgical exploration is preferable to a missed diagnosis as
all imaging studies have a false- negative rate
American Urological
Association
38
If the diagnosis is questionable, scrotal ultrasonography is readily
available; this test is the single most useful adjunct to the history
and physical examination in the diagnosis of torsion
Data from Thakkar HS, Yardley I, Kufeji D. Management of paediatric testicular torsion— are we adhering to Royal
College of Surgeons (RCS) recommendations. Ann R Coll Surg Engl. 2018; Dogan HS, Stein R, ’t Hoen LA, Bogaert
G, Nijman RJM, Tekgul S, et al. Do EAU/ ESPU guidelines recommendations fit to patients? Results of a survey on
awareness of spina bifida patients. Eur Urol Suppl. 2019; Kurtz MP. Evaluation of the pediatric patient with a nontraumatic acute scrotum. AUA Update Ser. 2015.
Due to the delay in ultrasound, the decision was made to take the patient directly to
theatre for urgent scrotal exploration. The patient was consented carefully for infection,
bleeding, infertility, as well as the possibility of right orchidectomy and contralateral
fixation. Under general anaesthesia, a midline scrotal incision was performed, and the
right testis was delivered. On opening the TV, the testis was found to be dark blue in
colour (Figure 37.1) and the cord was untwisted. Warm swabs were wrapped around
the testis for 10 minutes, but the testicular colour did not improve and orchidectomy
was performed. A three- point fixation of the contralateral testis was performed with
non- absorbable sutures. The patient was discharged the following morning after review.
Learning point Testicular fixation
Fixation of the testis to the inner scrotal wall prevents re- torsion. If torsion is diagnosed, contralateral
fixation must be performed as the BCD is usually present on both sides. The literature describes
several techniques for testicular fixation.
A popular method involves stitching a non- absorbable suture from the tunica albuginea (TA) to
the median septum or scrotal wall.
adhesions between the TA and inner scrotal wall.43 To reduce the risk of recurrence post fixation, the
technique of axial fixation at four points compared to three has been described.
12– 14,39,40
41,42
Another technique is to fenestrate the TV to produce strong
42
Figure 37.1 Dark blue testis during exploration for testicular torsion from ASUH, Cairo, Egypt 2017.
The main criticism of suturing of the TA is a breach of the blood– testis barrier, which may lead
100
(a)
90
80
70
60
50
40
30
20
10
0
0−6
Salvaged cases, %
7−12 13−18 19−24 >24
Time interval, h
>48
90
(b)
80
70
60
50
40
30
20
10
0
0−6
Salvaged cases with atrophy, %
6−12 12−24
Time interval, h
>24
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to impaired spermatogenesis.44 Animal studies have also suggested a higher level of anti- sperm
antibodies after orchidopexy.
pouch, to avoid suturing of the TA. The testis is fixed in an extravaginal position.
Other non- breaching techniques include a Jaboulay’s repair and reliance of adhesions between
testicular integuments49 as well as fixation of the TV to the dartos fascia.
45,46
Therefore, often paediatric surgeons use a subcutaneous dartos
47,48
45
Expert comment Contralateral testicular fixation
Catastrophic bilateral testicular loss has impelled recommendations for fixation of the contralateral
healthy testis, particularly in boys with BCD.
50,51
Some urologists have adopted similar practice with
other pathological causes, which may increase the risk of bilateral complications.52 Current guidance
from the American Urological Association recommends further research into the area as the longterm outcome data are lacking.53 In the absence of evidence- based guidelines, the decision for
contralateral testicular fixation should be based on experience and non- comparative retrospective
studies. Therefore, patients and their parents must be thoroughly counselled on both the advantages
and disadvantages of each option together with the possible implications prior to surgery.
54
Learning point Timing of testicular fixation
Door to detorsion time is an important and independent factor affecting testicular preservation and
survival. The literature demonstrates that fixing the torted testis within the first 6 hours has the highest
probability of salvage rates. This rate decreases with the length of delay in exploration and detorsion
of the testis (Figure 37.2).55 Another important factor includes prehospital delay. Fast efficient hospital
management improves the former and education may improve the latter.
56
367Case 37 Testicular torsion controversies
Figure 37.2 Immediate (early) surgical salvage rate after torsion (a) and subsequent atrophy rate
of surgically salvaged testes (b) after torsion of various time intervals.
From Visser and Heynes (2003).
55
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Evidence base Testicular fixation
Case studies have advocated fixation of testis despite the clinical appearance of ischaemia in a
case of a solitary testis.57 Often postoperatively normal testicular blood flow can be detected on
subsequent ultrasonography, testosterone levels normalize, and cryopreserved semen 50 hours later
can also be normal. Therefore, there is a chance of salvage despite the testis appearing completely
ischaemic.
A small study (n = 3) describing a technique to decrease ischaemia caused by localized compartment
syndrome by making a small window in the TA has been described.58 The team reported that the
intercompartmental pressure decreased dramatically and the colour improved. One case developed
this further by adding a TV flap for coverage and found the risk of orchidectomy was less than
fasciotomy alone (35.9% vs 15%).
Clinical tip Orchidectomy
Orchidectomy is the final surgical option and a delay in diagnosis will potentially lead to a necrotic
unsalvageable testis at exploration. Orchidectomy may be performed in up to 42% of surgically
explored cases.
the testis have failed and the testis remains unsalvageable. In this case, the surgeon should proceed to
orchidectomy.
It is extremely important to consent the patient carefully prior to surgery discussing all possible
findings, procedures, and complications of surgery.
Expert comment Testicular prosthesis
Post orchidectomy, a urologist must consider both the late effects of the surgery as well as the
patient’s body image. Insertion of a testicular prosthesis may help to restore patient self- esteem.
Around a quarter of testicular prosthesis insertions are performed post TT orchidectomy. Between
68% and 91% of men were satisfied with their prosthesis and body image postoperatively.63
Historical teaching recommends a delay in prosthesis insertion after torsion to avoid the
risk of infection. However, experience from breast surgeons who often insert silicone breasts
after mastectomy has changed the current concept of prosthesis timing.64 A recent study
demonstrated that simultaneous insertion of prosthesis with orchidectomy after torsion does
not increase complication rates.65 Moreover, the evidence supporting the concept of delayed
insertion is low level.
60,61
In all cases detorsion should be performed and only when all attempts to reperfuse
57,62
66
59
A final word from the expert
Although TT is one of the most frequent urological emergencies, there are still several controversial
areas in management as this chapter has highlighted. There is emerging evidence of an association
between TT and genetic disorders as well as an increased incidence in families.
causes remain unclear. No single symptom is solely pathognomonic of the disease20 nor is there
an effective imaging technique, which can differentiate diagnosis of TT with a high degree of
sensitivity and specificity.
24,32,33,68,69
Discrepancies in surgical technique, non- invasive manual detorsion, and surgical fixation still
rely on surgical experience and surgeon preference.
12,70
Minimizing long- term risk is paramount;
however, there is still no consensus on a superior suturing technique, three- point or four- point
fixation, and a TA protective approach.
14,46
Several medical therapies have been used in animal models but very few reliably translate to
humans.
71– 81
For clinicians to streamline management of this common condition worldwide
62,67
Environmental
and ensure uniformity of clinical practice, well- designed multicentre studies are required.
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Increasing litigation62 and more access to patients for information necessitates doctors to
participate and collaborate in studies to improve evidence- based practice for TT.
369Case 37 Testicular torsion controversies
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CASE
38
https://t.me/med1917
Priapism
Thomas Ellul and Nicholas Bullock
Expert commentary Ayman Younis
Case history
A 37- year- old gentleman presented acutely to the emergency department with a prolonged, painful erection. He had taken cocaine earlier in the day and subsequently
developed an erection that had not subsided for 8 hours despite ejaculation. This
was his first presentation with any urological complaint. Despite receiving analgesia
in the emergency department, he was in significant discomfort. The urologist on call
attended and following an examination, made a diagnosis of acute priapism.
Learning point Definition, classification, and epidemiology of priapism
Priapism is defined as complete or partial penile tumescence that persists for >4 hours in the absence
of sexual stimulation, or after ejaculation.
population being studied. This distinction is most relevant for populations with a high prevalence
of sickle cell disease (SCD) (a major risk factor for the development of priapism). Overall incidence
of priapism is estimated to be 1.5 per 100,000 and can occur in any age group. Typically, there is
a bimodal peak of incidence, between 5 and 10 years in children and 20 and 50 years in adults.4
Priapism is divided into three main subtypes: ischaemic, non- ischaemic, and stuttering priapism. The
aetiologies of these are summarized in Table 38.1.
Ischaemic or ‘low- flow’ priapism
This is a persistent erection marked by rigidity of the corpora cavernosa and by little or no cavernous
arterial inflow.1 The patient typically complains of penile pain and examination reveals a rigid erection
of the corpora with relative flaccidity of the glans. The ischaemic subtype accounts for 95% of
presentations with priapism. It is marked by rigidity of the corpora cavernosa with little arterial inflow
1– 3
Incidence rates of priapism vary, dependent on the
Table 38.1 Summary of aetiological factors for ischaemic and non- ischaemic priapism
Ischaemic priapism Non- ischaemic priapism
Idiopathic
Haematological disorders (SCD, thalassaemia, leukaemia,
multiple myeloma)
Infections (rabies, malaria, scorpion sting)
Metabolic disorders (amyloidosis, gout, homocystinuria)
Neurogenic disorders (syphilis, spinal cord injury,
cerebrovascular accident)
Neoplasms (pelvic/ perineal infiltration or metastases)
Medications (erectile dysfunction medications,
antipsychotics, recreational drugs)
Adapted from Johnson et al. (2019).
Blunt perineal or penile trauma
Metastatic malignancy to the penis
Acute spinal cord injury
Following intracavernosal injections
or aspiration
6
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